Introduction

The early detection, prediction, and risk stratification of liver cirrhosis and its sequelae eventually facilitate proper management of advanced liver cirrhosis with substantial improvement in patient outcomes. The synthesis of active Vitamin D3 involve the hepatic 25 hydroxylase enzyme, and the final step of activation occurs in the kidney. Vitamin D3 plays an essential role in calcium homeostasis and has been involved in the mechanisms of cellular proliferation, differentiation, and immunomodulation. 60-90% of chronic liver disease patients are vitamin D deficient. Whether this is a result or a cause, remains unclear. Vitamin D deficiency in liver disease has been linked to hepatocellular carcinoma, severity of alcoholic and non-alcoholic liver disease, and hepatitis B treatment outcomes.

Aims & Methods

*Was to assess the relation between vitamin D3 level, spontaneous bacterial peritonitis (SBP), and severity of liver dysfunction in patients with liver cirrhosis.
*In a case-control design, 50 patients with cirrhotic ascites who were categorized into two age- and sex-matched groups: 25 patients having liver cirrhosis, ascites with SBP; and 25 patients having liver cirrhosis, ascites without SBP. After clinical evaluation, laboratory investigations were conducted, including, liver test profile, hemogram, ascetic fluid analysis and culture. Serum level of vitamin D3 was measured using chemiluminescence immunoassay. Abdominal ultrasound for liver evaluation, as well as upper gastrointestinal endoscopy for varices screening/grading were done. The severity of liver disease was assessed by Child-Pugh and MELD-Na scores. Patient clinical outcome of SBP (inpatient mortality) was assessed.

Results

Low vitamin D3 level (i.e. < 30ng/ml) was present in 100% of patients with SBP, compared to 40% in patients without SBP. Patients with ascites and SBP had lower Vitamin D3 level compared to patients without SBP (13.3±4.5 ng/ml vs. 30.5±5.5 ng/ml, p<0.001). Low vitamin D3 (n = 35) were associated with low platelet count, lower serum albumen, higher serum bilirubin and INR (P < 0.001). In addition, low vitamin D3 was associated with more severe ascites (57% vs. 0.0% for normal vitamin D3 levels), high median MELD-Na (30 points vs. 11 points for normal vit D3), and higher Child-Pugh scores (p< 0.05). In addition, vitamin D level was highest in F1 varices, 24.6 (18.7- 31.9) ng/ml and lowest in F3, 12 (8-12) ng/ml. Patients without esophageal varices had sufficient serum vitamin D levels with a median of 36 (36- 39) ng/ml. Differences were statistically significant (where χ² of Kruskal-Wallis = 20.467, p= <0.001). Of patients with SBP, 16% died from septic shock and multiple organ failure, all of them had low vitamin D3 level < 30 ng/ml.

Vitamin D3 levels were also correlated to liver functions as well as severity scores (Table)

Parameter	Correlation coefficient (r)	P
MELD score	-0.836	<0.001
Child–Pugh score	-0.818	<0.001
Serum Albumin	0.765	<0.001
INR	- 0.732	<0.001
Serum Bilirubin	-0.550	<0.001
Platelets count	0.685	<0.001

Conclusion

Vitamin D3 level is suggested as a potential non-invasive prognostic biomarker for severity of liver disease where its associated with worse clinical outcomes. Its advised that vitamin D3 to be maintained at sufficient serum levels in cirrhotic patients because its deficiency is associated with worse liver functions and higher incidence of SBP morbidity and mortality.

References

-Wu YQ, Fan WZ, Xue M, Guo J, Wei JL, Wang Y, et al. 25-OH-vitamin D deficiency identifies poor tumor response in hepatocellular carcinoma treated with transarterial chemoembolization. Clin Transl Oncol 2020; 22(1):70-80.
-Yu R, Tan D, Ning Q, Niu J, Bai X, Chen S, et al. Association of baseline vitamin D level with genetic determinants and virologic response in patients with chronic hepatitis B. Hepatol Res 2018; 48(3):E213-21.
-Hariri M, Zohdi S. Effect of Vitamin D on Non-Alcoholic Fatty Liver Disease: A Systematic Review of Randomized Controlled Clinical Trials. Int J Prev Med 2019; 10:14.
-Borges-Canha M, Neves JS, Mendonça F, Silva MM, Costa C, Cabral PM, et al. The Impact of Vitamin D in Non-Alcoholic Fatty Liver Disease: A Cross-Sectional Study in Patients with Morbid Obesity. Diabetes Metab Syndr Obes 2021; 14:487-95.
-Bennouar S, Cherif AB, Kessira A, Bennouar DE, Abdi S. Association and interaction between vitamin D level and metabolic syndrome for non-alcoholic fatty liver disease. J Diabetes Metab Disord 2021; 20(2):1309-17.

Introduction

Hepatic decompensation in patients with cirrhosis represents a critical point in the clinical course of the disease, associated with a significant increase in morbidity and mortality. ¹ Common clinical manifestations of decompensation include ascites, hepatic encephalopathy, and variceal bleeding.^2​ Cystatin C, a low molecular weight cysteine protease inhibitor produced by all nucleated cells, has emerged as a reliable endogenous marker of glomerular filtration rate (GFR). Unlike serum creatinine, cystatin C is not significantly influenced by age, sex, muscle mass, or dietary protein intake, making it a more precise indicator of renal function—particularly in populations with altered muscle mass, such as those with chronic liver disease.³ Beyond its role in renal assessment, cystatin C has demonstrated prognostic value in various clinical settings, including cardiovascular disease, sepsis, and general critical illness^​4,5; however, patients with liver cirrhosis have been underrepresented in these cohorts.

Aims & Methods

Prospective longitudinal study including 62 patients with confirmed Child-Pugh class A or B cirrhosis. Serum cystatin C levels were measured at baseline by ELISA (mg/L), using <0.95 mg/L as the normal cutoff. Patients were followed for 6 months to detect decompensation events. Clinical and biochemical variables (age, sex, creatinine, albumin) were analyzed using quartile stratification, linear trend tests, Pearson’s chi-squared test, and diagnostic performance metrics (odds ratio, sensitivity, specificity, likelihood ratios).

Results

Table 1. Clinical and Biochemical Characteristics According to Hepatic Decompensation During Follow-Up.

Variable	Total (n = 62)	With decompensation (n =27)	Without decompensation (n = 35)
Age (mean ± SD, years)	58.05 ± 11.4	59.1 ± 10.9	57.2 ± 11.9
Male sex, n (%)	32 (51.6%)	14 (43%)	18(56%)
Serum cystatin C (mg/L, mean ± SD)	1.07 ± 0.42	1.25 ± 0.40	0.90 ± 0.40
Elevated cystatin C (>0.95 mg/L), n (%)	35 (56.4)	22 (81.5)	20 (57.1)
Serum albumin (g/dL, mean ± SD)	3.1 ± 0.5	2.8 ± 0.5	3.4 ± 0.4
Creatinine/cystatin C ratio (mean ± SD)	8.7 ± 5.8	7.6 ± 5.1	9.7 ± 6.1
Main etiology: Alcoholic liver disease, n (%)	26 (41.9)	12 (44.4)	14 (40.0)

Of 62 patients (32 men, 51.6%; mean age 58.05 ± 11.4 years), major etiologies were alcohol use (41.9%), metabolic liver disease (38.7%), and autoimmune disease (19.3%). Patients with infectious or undefined etiologies were excluded.
During follow-up, 27 patients (43.5%) developed at least one decompensation event (ascites, encephalopathy, or variceal bleeding). Among them, 81.5% had elevated cystatin C (mean 1.25 ± 0.40 mg/L) versus non-decompensated (mean 0.9 ± 0.40 mg/L, p<0.001). Chi-square analysis showed a significant association (χ² = 4.132; p = 0.042), supported by likelihood ratio (χ² = 4.293; p = 0.038) and linear-by-linear association (χ² = 4.065; p = 0.044). The estimated OR was 3.3.
Decompensated patients had a lower creatinine/cystatin ratio (mean 7.6 ± 5.1 vs 9.7 ± 6.1), though not statistically significant (p=0.162). Albumin levels were lower (2.8 ± 0.5 g/dL vs 3.4 ± 0.4 g/dL, p<0.001).
Quartile analysis showed a higher risk of decompensation in the highest cystatin C quartile (>1.25 mg/L; p<0.001, linear trend), even after excluding patients with eGFR <60 mL/min/1.73 m². This trend was confirmed by linear-by-linear association (χ² = 39.88; df = 1; p < 0.001).

Conclusion

Cystatin C is significantly associated with the development of decompensation events in patients with chronic liver disease, providing an OR of 3.3 and a consistent dose-response trend across quartiles. Although the final sample size was relatively small due to exclusions for loss to follow-up or incomplete biochemical studies, the results were statistically significant and clinically relevant. These findings, based on a prospective design and strict follow-up, suggest that cystatin C could be a prognostic marker, and its inclusion in clinical practice warrants prospective validation.

References

1. Zhai M, Long J, Liu S, Liu C, Li L, Yang L, Li Y, Shu B. The burden of liver cirrhosis and underlying etiologies: results from the global burden of disease study 2017. Aging (Albany NY). 2021 Jan 12;13(1):279–300. doi: 10.18632/aging.104127.
2. D'Amico G, Bernardi M, Angeli P. Towards a new definition of decompensated cirrhosis. J Hepatol. 2022 Jan;76(1):202–207. doi: 10.1016/j.jhep.2021.06.018.​
3. Chen DC, Potok OA, Rifkin D, Estrella MM. Ventajas, limitaciones y consideraciones clínicas en el uso de la cistatina C para estimar la TFG. Riñón360. 2022;3(10):1807-14.
4. Wang Y, Li W, Yang J, Zhang M, Tian C, Ma M, Zhang Q. Association between cystatin C and the risk of ischemic stroke: a systematic review and meta-analysis. J Mol Neurosci. 2019;69(3):444–449. doi:10.1007/s12031-019-01373-1.
5. Luo J, Wang LP, Hu HF, Zhang L, Li YL, Ai LM, et al. Cystatin C and cardiovascular or all-cause mortality risk in the general population: a meta-analysis. Clin Chim Acta. 2015 Oct 23;450:39–45. doi: 10.1016/j.cca.2015.07.016.

Disclosure

I declare that I have no conflicts of interest related to this work.

Introduction

Fatty liver is sensitive to ischemia-reperfusion injury [1, 2]. At the microcirculatory level, the structural and functional properties of red blood cells (RBCs) play a key role, since the degree of hypoxia in liver tissue depends on their ability to deform, tendency to form aggregates, and hemolysis [3], which, in turn, is a factor in fibrogenesis [4].

Aims & Methods

Research objective is as follows: To study the associations of viscoelastic, electrical parameters of RBCs and levels of FAs of their membranes, serum in patients with fatty liver disease.
84 men (average age 48.4±13.9 years) with fatty liver disease (FLD) of various genesis (alcoholic, non-alcoholic, of mixed genesis: alcoholic+metabolic), various necroinflammatory activity with fibrosis F0-1 (FibroScan® 502 (Echosens, France) have been examined. The study of RBC electrical, viscoelastic parameters has been performed by dielectrophoresis. The content of FAs in RBC membranes and blood serum has been determined using gas chromatography-mass spectrometry (Agilent 7000B, USA).

Results

It has been found, that RBC indices reflecting their deformation ability (amplitude of deformation at 10⁶ Hz, degree of deformation at 0.5x10⁶ Hz), membrane state (capacitance), surface charge value (dipole moment, speed of cell movement to electrodes), RBC resistance (polarisability) were directly correlated with the levels of n-3 PUFAs in RBC membranes, blood serum, both their total content and concentrations of individual FAs (C20:5n-3, C22:5n-3, C22:6n-3), the level of monounsaturated oleic FAs, as well as two SFAs (C15:0, 17:0). On the contrary, the associations with the predominant part of SFAs, both individual (especially highly accurate: with C16:0, C18:0) and total content, MUSAs, USAs, including ratios of n-6/n-3 PUFAs, SFAs/UFAs, SFAs/PUFAs, were inverse (p=0,02-0,0000001).
The summarized rigidity was related with high strength of association and statistical significance to RBC content of C16:0 (r=0.674, p<0.000001), C18:0 (r=0.443, p<0.000006), C18:2n-6 (r=0.345, p=0.0006) FAs, total SFAs (r=0.640, p<0.000001), the ratios of n-6/n-3 PUFAs (r=0.605, p<0.000001), SFAs/PUFAs (r=0.428, p=0.000015).
Correlations with RBC levels of C16:0 (r=0.551, p<0.000001), C18:2n-6 (r=0.470, p=0.000042) were the closest for membrane conductivity levels, total SFAs (r=0.484, p<0.000001), USAs (r=0.468, p<0.000001), MUSAs (r=0.504, p<0.000001), n-6 PUFA (r=0.414, p=0.00003), as well as for ratio of n-6/n-3 PUFAs (r=0.568, p<0.000001).
Associations of high strength and statistical significance for RBC aggregation index have been found concerning RBC C16:0 (r=0.691, p<0.000001), C18:0 (r=0.486, p<0.000001), for the total UFAs' content (r=0.672, p<0.000001), the ratios n-6/n-3 PUFAs (r=0.611, p<0.000001), SFAs/UFAs (r=0.475, p<0.000001), SFAs/PUFAs (r=0.478, p<0.000001).
RBC destruction indices have been found to be directly related to the total UFAs' content in both RBC membranes and serum, RBC levels of C20:3n-6 (r=0.205, p=0.046), and inversely related to the content of C15:0 (r=-0.224, p=0.028), C17:0 (r=-0.151, p=0.039) and C18:1;c9 (r=-0.206, p=0.045).

Conclusion

The identified associations indicate a dependence of RBC parameters on the levels and ratios of FAs in their membranes, serum. Deterioration of blood rheological properties in patients with FLD is a factor associated with increasing hypoxia in liver tissue with potential for fibrogenesis and progression. The ability to modulate electrical, viscoelastic parameters of RBCs by exposure of FAs, including dietary FAs, defines new additional treatment targets for patients with FLD.

References

1. Farrell GC, Teoh NC, McCuskey RS. Hepatic microcirculation in fatty liver disease. Anat Rec (Hoboken). 2008 Jun;291(6):684-92. DOI: 10.1002/ar.20715
2. Patrono D, De Stefano N, Vissio E, et al. How to Preserve Steatotic Liver Grafts for Transplantation. J Clin Med. 2023 Jun 12;12(12):3982. DOI: 10.3390/jcm12123982
3. Brun JF, Varlet-Marie E, Myzia J, et al. Metabolic Influences Modulating Erythrocyte Deformability and Eryptosis. Metabolites. 2021 Dec 21;12(1):4. DOI: 10.3390/metabo12010004
4. Ramalho FS, Fernandez-Monteiro I, Rosello-Catafau J, Peralta C. Hepatic microcirculatory failure. Acta Cir Bras. 2006;21 Suppl 1:48-53. doi: 10.1590/s0102-86502006000700012

Introduction

Currently, non-alcoholic liver disorder (NAFLD) is the most predominant chronic liver disorder. NAFLD has been linked to hepatic and extra-hepatic morbidities. The need for non-invasive prediction of hepatic and extra-hepatic consequences of NAFLD is a demand, due to the complexity of the disease, high burden, and the need for early intervention.

Aims & Methods

to investigate the role of serum microRNA-130b and liver stiffness [as measured by acoustic radiation force impulse (ARFI)], to non-invasively predict chronic kidney disease (CKD) in NAFLD patients.
Patients and Methods: In a case-control design, we included 40 NAFLD patients (20 NAFLD with CKD, and 20 NAFLD without CKD), and 20 healthy controls. After clinical evaluation, laboratory assessments including liver test profile, renal function test, and quantification of microRNA-130b were done. Liver stiffness was evaluated using ARFI.

Results

The median values (interquartile range “IQR”) of mRNA-130b in patients with NAFLD+CKD, patients with NAFLD without CKD, and healthy subjects were [32.10 (27.3 -37.3), 27.01 (24.8 – 31.7), and 25.36 (23.5 – 27.1), copies/µl, respectively, P <0.001]. The median (IQR) value of Liver stiffness as measured by ARFI was significantly higher among NAFLD with CKD patients compared to NAFLD without CKD [2.97 (2.87 – 3.3) vs. 2.45 (2.18 – 2.8) m/sec, P = 0.002]. The median (IQR) value of microRNA-130b was significantly higher among NAFLD with CKD patients compared to NAFLD without CKD [P = 0.032]. In the current study, ARFI readings were negatively correlated with platelet count (n = 40, rs = -0.33, P = 0.038). ARFI readings were positively correlated to serum mRNA-130b values in both groups (rs = 0.49, P = 0.02 and rs = 0.64, P = 0.002, respectively). At a cut-off value > 28.13 copies/µl, microRNA-130b could differentiate between “NAFLD with CKD” and “NAFLD without CKD” patients with a sensitivity and specificity of 75%, and 70 %, respectively (AUC = 71.9 %, P = 0.018, 95% CI: 0.56 – 0.87). Similarly, At a cut-off value > 2.81 m/sec, ARFI could differentiate between “NAFLD with CKD” and “NAFLD without CKD” patients with a sensitivity and specificity of 80% (AUC = 77.8 %, P = 0.003, 95% CI: 0.62 – 0.93).

Conclusion

MicroRNA-130b and liver stiffness measurements are suggested as potential markers for the prediction of CKD among NAFLD patients. Serum microRNA-130b, and ARFI are valuable non-invasive tools for the assessment of NAFLD severity.

Introduction

Increased intestinal permeability, mediated by zonulin, has been implicated in the pathogenesis of insulin resistance, dyslipidemia, and non-alcoholic fatty liver disease (NAFLD). Small intestinal bacterial overgrowth (SIBO) may further contribute to metabolic dysfunction through endotoxin-induced inflammation.

Aims & Methods

The aim was to determine zonulin concentrations in patients with dyslipidemia and NAFLD and analyze their relationships with metabolic parameters and the prevalence of small intestinal bacterial overgrowth (SIBO). A total of 342 patients with dyslipidemia were enrolled; NAFLD was confirmed in 152 of them based on ultrasound and steatometry. Fecal zonulin levels were measured using ELISA; SIBO was assessed by hydrogen breath test. Lipid profiles, high-sensitivity C-reactive protein (hsCRP), and HDL-C levels were also analyzed.

Results

Zonulin levels in patients with NAFLD (115±2.76 ng/g) exceeded the normal range (≤107 ng/g), compared to 87±0.28 ng/g in the dyslipidemia group without NAFLD (p<0.05). SIBO was present in 45% of dyslipidemic patients and 53.2% of those with NAFLD. A positive correlation was found between zonulin and hsCRP (r=0.65) and triglycerides (r=0.58), and a negative correlation between SIBO and HDL-C (r=–0.78) in the dyslipidemia group.

Conclusion

Elevated zonulin and increased intestinal permeability are associated with higher cardiometabolic risk in patients with NAFLD and dyslipidemia. Both zonulin and SIBO may serve as potential therapeutic targets for preventing progression of NAFLD and related metabolic disturbances.